precheck-inForm

As of Tuesday, June 15, we will allow clients back into the building with their pets. If you do not wish to come in, we understand and will continue offering curbside. A mask covering the mouth and nose must be worn at all times when interacting with our staff either inside the clinic or curbside.

When you arrive in the parking lot please call or text to check in for your appointment. Please let us know if you would like to come into the clinic for your appointment OR if you would like to stay curbside.

The technician will come out to your car and either escort you and your pet to an exam room OR take your pet inside for the exam while you remain in your car.

We ask all clients to please answer the COVID questions BEFORE your appointment. If you will remain curbside for your appointment we will also ask that you fill out some questions regarding your pet’s health and the reason for your visit.

If you choose to remain curbside during the appointment, our technician will ask for your credit card number when they come out to get your pet for their appointment. We will not charge your card until you speak to the doctor and discuss the treatment plan and charges.

Your patience and understanding during this ever-evolving process is greatly appreciated!

Thank you for trusting us with your beloved pet’s health needs. Take care and stay safe!

Client Name*

Pet's Name*

Appointment Date*

Appointment Time*

Name of Person Bringing Pet*

Preferred Email Address*

Preferred Phone Number*

QUESTIONS REGARDING COVID19

Have you or anyone in your household traveled out-of-state or by plane within the past 14 days?*

Yes

Have you or anyone in your household experienced any cold or flu-like symptoms within the last 10 days? This includes the following symptoms: fever (at or over 100.4 F), chills, cough, shortness of breath/difficulty breathing, or new loss of taste or smell.*

Yes

Have you or anyone in your household tested positive for COVID-19, or been exposed to anyone that has tested positive for COVID-19 within the last 10 days?*

Yes

Are you currently on a quarantine or isolation order?*

Yes

Are you fully-vaccinated against COVID19?

Yes

While requesting vaccine status is well-established not to be a HIPAA violation, you may choose not to answer that question on our form. For the safety of our staff and others, in the event that a client declines to share their COVID-19 vaccine status, we work under the assumption that the individual is not vaccinated. When you come for your appointment, please be sure to wear a properly fitting mask over your mouth and nose during the entirety of your visit. Thank you.

For further clarification on the law, please refer to the section titled “Is it a HIPAA Violation to Ask about COVID Vaccines?” at this link from the HIPAA Journal: https://www.hipaajournal.com/is-it-a-hipaa-violation-to-ask-for-proof-of-vaccine-status/.

Reason for Visit: (check all that apply)

EXAM:

OTHER SERVICES:

Please explain further

Are there any concerns for:

(check all that apply)

Eating habits - please explain further